"The nurse breached protocol"

[magical thyme]

PPEs in a BSL-4 research lab



PPEs in Africa



PPEs with droplet precautions



I can't believe how quickly they blamed the nurse here and the volunteer nurse's aide (with all of 10 minutes training) in Spain. It couldn't possibly be that the precautions are insufficient.

[hobbit709]

1. Proper training is the problem. The equipment does what it's designed to do.

[magical thyme]

2. I've had gram stain permeate my gloves on 2 occasions

The gloves can be defective, they tear easily, and can get a pinprick while working with sharps.

And the photo of the ED worker preparing to take in the sheriff shows a spot on his neck exposed.

But proper training with practice certainly would help.

[Warpy]

33. It worked fine for HIV

It allowed MRSA to be tracked into the community.

It is not adequate for Ebola-Zaire.

Better gear and better training are to be had in Africa. 30% of the deaths in Africa are among health care workers, mostly nurses, in equipment that is superior to ours and decontaminated when they leave the ward.

The CDC had better stop listening to hospital bean counters and get serious about what needs to be done to care for these people without killing hospital workers.

[Kelvin Mace]

3. Protocols are no damned good

unless:

1) They are taught, explained and enforced.

2) All proper supplies are available.

Here is what you do, why you do it and you will do it. Here are the supplies to do it.

If the hospital failed either of these two rules, then the nurse is not to blame.

[magical thyme]

4. note the difference in coverings of the biohazard suit with negative pressure hood

and splash guard down to the wrist level. A worker who will shower in a chlorine wash in a decontamination room and undress with assistance.

The worker in Africa completely covered with 3-4 pairs of gloves. Who dressed with a spotter, will be showered in chlorine wash and undress with assistance.

Ebola clearly required extraordinary precautions that are not available to ordinary hospitals.

[Malraiders]

5. A student nurse in Africa made her protective wear from trash bags, rubber gloves and

rubber boots and a a rain jacket to treat 4 family members. Sadly one person succumbed to the virus but three survived.



From CNN's site: http://www.cnn.com/2014/09/25/health/ebola-fatu-family/

[quote]Every day, several times a day for about two weeks, Fatu put trash bags over her socks and tied them in a knot over her calves. Then she put on a pair of rubber boots and then another set of trash bags over the boots.
She wrapped her hair in a pair of stockings and over that a trash bag. Next she donned a raincoat and four pairs of gloves on each hand, followed by a mask.

It was an arduous and time-consuming process, but Fatu was religious about it, never cutting corners.[/quote]

[magical thyme]

7. and the student nurse wasn't doing the kind of risky procedures the Dallas nurse

was involved in.

Because one person didn't make a single mistake or have a single accident and got lucky, doesn't mean everybody will.

[Malraiders]

15. The student nurse in Africa was caring for 4 of her

family members in the family home in Africa.

The Dallas nurse who contracted the virus was caring for Mr. Duncan in a modern hospital in Texas with modern protective equipment and a procedure that was in place for the protection and benefit of the medical staff.

I find your conclusion unfounded that the student nurse was not doing the same risky procedures as the Dallas nurse.

Please clarify if possible.

[magical thyme]

17. the student nurse did not intubate her patients, nor did she remove intubation, nor did she

perform dialysis on them. She did not catheterize her patients, nor remove a catheter, nor remove urine for analysis. She did not draw blood repeatedly to monitor coagulation, chemistries, blood count, platelet count, etc. Those are just a few of the procedures that our modern hospitals provide that put you in very close contact with highly infectious body fluids and put you at higher risk of accidental exposure.

Those are the kinds of close contact body fluid procedures that the nurse was or may have been doing.

Is that clear enough for you?

[Malraiders]

20. No. Hospital policy sets the permissions for the nurses to

intubate a patient or insert a catherter and blood work is done by a lab tech in most hospitals.

Most of the tasks you say the nurse performed are not usually performed by a floor nurse.

Most facilities do not even allow nurses to intubate a patient. Fear of law suits maybe.

Would you carte to provide a source?

[LisaL]

27. What source do you want?

CDC is looking into whether this TX nurse got infected during ventilation or dialysis procedures. Only stands to reason she was involved in these procedures. Because if she wasn't, why would CDC look into whether she was infected during these procedures? Just for fun?

[Malraiders]

35. The fact that CDC is investigating to see if the Dallas nurse was involved and was exposed during

these procedures does not mean that she was involved in those procedures. It means INHO that there is an investigation being conducted by CDC to discover how the Dallas nurse was exposed.

Edit added:

And since initially the Dallas nurse was not one of the 48 health care workers who were being most closely watched after caring for Mr. Duncan, it would seem logical to deduce that the Dallas nurse was not conducting the high risk procedures that you listed.

[LisaL]

36. If she wasn't there during the procedures, why would CDC suggest she could have been infected

during these procedures?
Seriously?
Are you suggesting Ebola is airborne and can travel large distances, or what?

[Malraiders]

38. The edit that I posted that you may have missed:

And since initially the Dallas nurse was not one of the 48 health care workers who were being most closely watched after caring for Mr. Duncan, it would seem logical to deduce that the Dallas nurse was not conducting the high risk procedures that you listed.

[LisaL]

41. No, it wouldn't be logical.

Because you are completely wrong. 48 people monitored were not health care workers, but Mr. Duncan's contacts before he was admitted.

[magical thyme]

40. as I initially wrote, she may have been involved in some of those procedures

"she could have come into contact with infected fluid as Duncan received kidney dialysis or respiratory intubation."
http://www.cnn.com/2014/10/13/health/ebola-nurse-how-could-this-happen/index.html

If a patient is a tough stick -- and somebody who's blood vessels are compromised by severe inflammation plus direct attack on the endothelial cells as Duncan's were is likely to be a tough stick, as well as somebody who is dying with circulation is stopping -- it is not uncommon to pull blood from an IV instead of sticking them over and over looking for a functional vein. And phlebotomists and lab techs don't pull the blood from the IV; the attending nurse does it for us.

[magical thyme]

50. and here is a 2nd source. The second nurse catheterized and drew his blood.

http://www.dailymail.co.uk/news/article-2793691/second-healthcare-worker-tests-positive-ebola-texas.html

I'm not able to get through to the link right now, but was able to read it this morning.

[LisaL]

26. She wasn't doing the same risky procedures.

She wasn't putting her relatives on dialysis or ventilation.
Dialysis and ventilation are high risk procedures for spreading the virus.

[Sunlei]

11. The dedication of Africias medical care givers is Heroic.

[LisaL]

29. There are some people who have immunity to Ebola.

Probably because they were exposed to low lever of the virus and became immune.
Which would be possible for a woman in Africa.
Not possible for a woman in Dallas, TX.

[SoCalDem]

6. Can't have some uppity nurse trying to sue her employer

[Fumesucker]

8. What does her spotter/helper say?

The language I've read sounds like she got out of her gear on her own.

[magical thyme]

10. I'm guessing they don't have "spotter/helpers" in the hospital setting

I know we don't ordinarily do that where I work, and are so short-staffed already we probably couldn't.
We also don't have decontamination exit and undress areas, although maybe they set something like that up for Duncan.

In Africa, they have an entrance only and an exit only into the decontamination area. Same thing in the BSL-4 research labs.

[Fumesucker]

13. That was my guess too..

I was looking at another thread and I gathered that a spotter is part of the protocol for Ebola but I could have that wrong.

[etherealtruth]

22. Back in the day a "spotter" was required for all folk working in isolation

... I don't know when that changed ....?

[Sunlei]

9. doubt thehair/skin is exposed like in the pic. 'mistakes' happen, even with the best medical people.

[Savannahmann]

12. What is interesting is that the people who work on Ebola in the lab

Those folks wear PPPS or Positive Pressure Protective Suits. Isolated environment with filtered air. This is what the "experts" use when studying Ebola in a lab. For the rest of us, oh you'll be fine with cloth mask and some gloves. Just wash your hands often, and if you get it we'll blame you for "breaking protocols".

When we see them in the lab with a cloth mask and some flimsy rubber gloves, I'll believe it's safe. Because patients in agony, and Ebola is very painful, sometimes thrash and flick things out that are unnoticed. Perhaps even breathed in despite the flimsy paper mask.

By the way, weren't those masks designed to keep the Doctors from breathing onto patients in surgery? An effort to reduce the presence of bacteria or contaminants into open wounds?

[magical thyme]

14. there are different types of masks for different purposes

droplet protection masks are designed to prevent droplets from getting in or out. TB masks are designed to keep TB from getting in.

[librechik]

16. at the root of the problem: understaffing and underpaying caregivers.

IMO

[Louisiana1976]

37. And at the root of both: greed. A profit-driven hospital's desire to maintain profits instead of

providing care adequate to prevent caregivers from being exposed to Ebola infection.

[Bluenorthwest]

18. If there is 10 minutes of training, my guess is that is where the infuffiency lies....

That's just logical. It is negligent to have untrained people in an environment where errors can be fatal.

[LeftInTX]

19. Another pic from Nebraska Biocontainment Unit

http://www.washingtonpost.com/wp-apps/imrs.php?src=&w=1484
Angela Hewlett runs a drill in February 2012 at the Nebraska Biocontainment Unit, where a second Ebola patient is being treated. (Taylor Wilson/Nebraska Medical Center)

More pics and info at link
http://www.washingtonpost.com/posteverything/wp/2014/10/10/i-treated-one-of-the-american-ebola-patients-like-you-i-was-anxious-too/

I don't think the nurse in Dallas had this type of PPE

[LisaL]

25. If nurse in Dallas was folloing CDC guidelines, then she didn't have this type of PPE.

This one seems to be wearing a biohazard suit underneath the head covering. CDC doesn't require neither the suit nor head covering.

[LeftInTX]

34. Yes, I agree

Pic was to contrast what the doctor in Nebraska was wearing versus what the nurse in Dallas was wearing.

[morningfog]

21. Do you have a link where the CDC said the nurse breached protocol?

Serious question. I read the CDC say "protocol was breached." Which is different than "the nurse breached protocol."

The CDC also said there will likely be more infections of health workers who treated Duncan "due to the same breach."

[LisaL]

24. Who would breach it if not the nurse?

She is the one infected. If the protocol was perfect, but she got infected, then the only logical conclusion is that she breached it.

[morningfog]

28. The protocol could be breached institutionally.

[LisaL]

30. Look a the PPEs in the guidelines and tell me they are adequate.

CDC doesn't even ask for head covers.
Shoe covers are only required to be worn in certain situations (if body fluids are on the floor).
Now look at what doctors wear in Africa, and tell me that these guidelines are perfectly adequate.

[morningfog]

31. That has nothing to do with whether the CDC

blamed a breach on the nurse or the hospital.

[magical thyme]

39. of course they said it 3rd person.

Responding to questions, Dr. Tom Frieden, the director of the Centers for Disease Control and Prevention, said the worker hasn't identified a specific moment that might have led to the breach.
http://www.npr.org/blogs/thetwo-way/2014/10/12/355537175/texas-health-care-worker-tests-positive-for-ebola


Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID) told Chuck Todd today on NBC News’ Meet the Press that there was clearly “an inadvertent breach of protocol” that led to the health worker being infected.

While he says that we don’t know the details of the breach, Dr. Fauci mentioned that removing personal protective equipment after a long shift has sometimes been associated with the infection of health care workers.http://www.forbes.com/sites/davidkroll/2014/10/12/dallas-nurse-who-cared-for-duncan-contracts-ebola-inadvertent-breach-of-protocol/



"You don't scapegoat and blame when you have a disease outbreak," said Bonnie Castillo, a registered nurse and a disaster relief expert at National Nurses United, which serves as both a union and a professional association for U.S. nurses. "We have a system failure. That is what we have to correct."
http://www.reuters.com/article/2014/10/13/us-health-ebola-usa-nurse-idUSKCN0I206820141013

Dr. Gavin Macgregor-Skinner, an expert on public health preparedness at Pennsylvania State University, also disagreed with the talk of a breach of protocol, saying it just puts the onus on the nurse.
http://www.huffingtonpost.com/2014/10/13/protocol-breach-ebola-cdc-tom-frieden-nurse_n_5974828.html

[LisaL]

23. I am with you.

CDC guidelines don't even require head covers. Look at all the exposed skin on the person in droplet/contact precautions set up.

[lovuian]

32. Just heard on CNBC that CDC is backing off

"breach of protocol" idea
and gone to "We don't know"

[Vinca]

42. I never took the remark as a slam at the nurse.

It's obvious protocol was somehow broken or she wouldn't be infected. Most likely an edge of a garment made contact with her skin. Having had just enough medical training to be dangerous, the procedures used in this case have to be slow and meticulous to keep caregivers from being exposed to the virus. The fact is, hospital workers are not used to the kind of precautions needed in these cases. If you break the procedure for a case of the flu, you usually recover . . . no big deal. They may not be prepared mentally or by training for ebola. I'm beginning to think regional treatment centers, like the facility in Nebraska, are the way to deal with patients.

[LisaL]

43. No, it's not obvious.

CDC hasn't identified how she supposedly broke protocol.

[Vinca]

44. How would they know? They weren't there.

The ebola virus is invisible. It's not going to hop off the protective gear, glow neon and land on your hand.

[HereSince1628]

48. My guess would be by questioning her

and by questioning co-workers about her behaviors or events she was involved in that might have led to contamination.

How else could they know?

on edit, we don't know from the news media that such debriefing took place and were shared with CDC.

[magical thyme]

45. if the protocol is inadequate then it's not a breach of protocol, it's inadequate protocol.

The nurses in critical care are quite used to droplet precautions. She didn't have to make a single mistake.

But the health care workers treating patients at the BSL-4 labs aren't using standard droplet precautions. They're wearing closer to biohazard suits, trained for years, have spotters helping them dress and undress and even have a monitor while treating. Same as researchers. Same as the health care workers in the Ebola countries.

"Having had just enough medical training to be dangerous,"
I don't even know how to respond to such an arrogant, smug statement.

[SidDithers]

46. German hospital: UN medical worker dies of Ebola

http://news.yahoo.com/german-hospital-un-worker-dies-ebola-082155030.html

BERLIN (AP) — A United Nations medical worker who was infected with Ebola in Liberia has died despite "intensive medical procedures," a German hospital said Tuesday.

The St. Georg hospital in Leipzig said the 56-year-old man, whose name has not been released, died overnight of the infection. It released no further details and did not answer telephone calls.

The medical worker was infected in Africa, presumably wearing the PPE pictured in the OP.

Are those precautions now insufficient too?

Sid

[LisaL]

47. You have no idea how he was infected, do you?

He was living in Liberia after all.
He could have been in contact with someone infected while not wearing any protective gear whatsoever.

[magical thyme]

49. exactly what LisaL wrote above. Just as Brantly and Writebol may have picked it up from a

local person while not in their PPEs. Local health care workers go home to their potentially exposed families and come back to work potentially exposed. There was a local health care worker helping them to decontaminate who also came down with Ebola.

And the non-locals don't wear their PPEs 24x7 and don't live in quarantine.